Request Online Access

If you applied for Patient Access with this practice before August 2015, please re-apply using this amended form.

Victoria Park Medical Centre is providing registrations for Patient Access which will allow our patients to:

  • book and cancel appointments online
  • view appointments they have already booked (either online or by telephone)
  • request repeat prescriptions
  • keep their details (e.g. telephone numbers, address, etc) up to date

If you would like to request a registration form for Patient Access, fill in the form below.

Please enter all details below. Please ensure that your contact details are correct as these will be used to verify your identity and then notify you via e-mail when your registration form is ready to pick up.

In some cases, our emails may be incorrectly marked as spam - please check your Spam folder on your email account if you do not receive a reply from us within seven days.

Full Name
Date of Birth (dd/mm/yyyy)
Mobile Telephone Number
Email Address
First Line of Address

Important

The information submitted on these forms is sent to us via normal (non-encrypted) email, and we cannot guarantee that the information will not be seen by others. We accept no responsibility for the loss or interception of data before it reaches our server.